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Just Culture

Establishing a safety learning environment

Mary Coffey

Just Culture

Encouraging reporting of Incidents and near incidents Unsafe practices

To enable learning To establish a safety environment

Just Culture

Human error is a fact of life Cannot be eliminated Frequency can be reduced

How are human errors managed?

Just Culture

Human error is a fact of life Blame No blame Just culture

Blame Culture

It has to be someone’s fault Disciplinary approach An ‘easy’ option Sometimes appropriate

Blame Culture

Frequently not the fault of the individual

Discourages reporting Failure to learn Likelihood of repeat incidents

No blame Culture

Not the individual but the system Individuals reporting are not

subject to sanction/disciplinary action

Can introduce complacency Not always appropriate

Just Culture

An atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information… but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.”

Prof. James Reason

Just Culture

Human error is a fact of life Competent professionals make

mistakes Develop shortcuts (routine violations)

Just Culture

Human error is a fact of life Developing a learning rather than a

blaming culture Learning from unsafe acts Responding

Just Culture

Trust is central to the development of a just culture

We need to learn from our mistakes To understand the underlying causes

and address them

Just Culture

Not always blame free A balance between the benefits of

learning from incidents and the need for personal accountability

Repeated or careless behaviour Transparent disciplinary policy

Just Culture

Well established in Aviation, Nuclear Industry and some areas of health care

Just Culture

The Danish Naviair experience The introduction of non-punitive

reporting for aviation professionals in 2001

Number of reports in Danish air traffic control in the first year rose from approx. 15 per year to over 900

Just Culture

The Danish Naviair experience Previously unreported events Identification of risks and trends Opportunities to address latent safety

problems Potential major improvement in safety

GAIN working group

Just Culture

Medical Event Reporting System for Transfusion Medicine (MERS-TM) A standardised means of organised

data collection and analysis of transfusion errors, adverse events and near misses.

Just Culture

Medical Event Reporting System for Transfusion Medicine (MERS-TM) Effectiveness depends on the

willingness of individuals to report such information

David Marx

Just Culture

Not about reporting but learning from the reporting

Just Culture – Why?

…one million people injured by errors in treatment at hospitals each year in the US, with 120,000 people dying from those injuries

Just Culture – Why?

Organisational Culture in a helath care setting impacts the performance of the both organisation and the staff

Just Culture – Why?

the single greatest impediment to error prevention is …. that we punish people for making mistakes”

Dr. Lucian Leape briefing a US Congressional subcommittee

Just Culture – Why?

Health care workers reluctant to report Disciplinary based work environment Failure on their part Loyalty to colleagues

Just culture - Why?

Modern radiotherapy is a very complex process Technologically advanced and evolving

at a rapid pace

Just culture - Why?

Modern radiotherapy is a very complex process Requires the accurate application of

high technology planning and treatment in an holistic environment

A six week course of radiotherapy requires over 1000 parameters to be specified (ICRP 86)

Just Culture - Why?

Modern radiotherapy is a very complex process Encompasses technical, clinical, and

psychosocial management of individual patients

Requires collaborative teamwork It is expensive but subject to national

and local budgetary constraints

Just Culture - Why?

Modern radiotherapy is a very complex process There are multiple processes, complex

calculations and many systems where failures can occur

Strongly dependent or influenced by human factors

High risk and error prone

Just Culture - Why?

Modern radiotherapy is a very complex process From experience in centres with well

developed reporting systems the number of near incidents or incidents with no detrimental effect is high

? A missed opportunity to learn and improve

Just Culture

The ROSIS experience Consistency of error type across

departments and across countries Can learn from each other

Learning from the ROSIS experience

Where in the process are errors most likely to occur?

Where in the process are errors detected?

Learning from the ROSIS experience

Do certain situations give rise to more or more serious errors Stage in the process Technique Equipment Working environment

Just Culture - caution

Introduction of a “just” disciplinary policy is not enough to bring about a just culture; the blame reflex is highly resilient

Derek Ross, Psychology Department TCD

Just Culture - caution

Requires an appreciation of the complexity of human behaviour and human error and how errors are managed

Just Culture - caution

Once introduced the report form and reporting can become the focus

The emphasis should be on the reasons for reportingTo learnTo reduce error potential

Reporting and Quality Improvement

Report

analysis

feedback

Change of practice

Review of effectiveness

Raising awareness

Safer practice